ECONOMIC INJURY

You will eventually need to prove in a court of law your loss through documentation in order to receive compensation. You will not need to prove your loss here. This form is for those that were not simply inconvenienced by Ohio's emergency public health orders. This form is for:

Those individuals that lost their jobs or wages were significantly.
Businesses that had to declare bankruptcy for a lack of sales due to social distancing mandates.
Businesses that had reduced sales due to curfews and social distancing mandates.
Businesses that were cited and had to defend their liquor license or business license in with the Ohio Liquor Control Commission or the Ohio Industrial Commission (You were cited by either the OIU, Ohio Investigative Unit, or by agents of the BWC, Bureau of Workers' Compensation.)

Economic Injury

A Petition of affidavit is not an affidavit. It is a petition that if called upon - you will submit a notarized affidavit.

**You must be a United States Citizen
**You must be registered to vote for positive identification

First Name*

M.I.

Last Name*

Address 1*

Address 2*

City*

State*

Zip*

Phone Number*

Email address*

County you are registered to vote in*

Type

Individual

Business

Business Name

OWNER

Business Address 1

Business Address 2

B-City*

B-State*

B-Zip*

Business Phone

County Business is located in

Have you participated in an administrative hearing before the Ohio Department of Liquor Control?

Case Number

Permit Number

Have you participated in an administrative hearing before the OBWC Industrial Commission?

Case Number

License Number

Describe your Economic Injury*

Minimum amount you believe you should be compensated?*

Maximum amount you believe you should be compensated?*

Upload a prepared Affidavit now, if you have one. As a .pdf or .docx format.

Drop files here or click to select

Date*

Time*